Dr. Robert Wachter, Author of the “The Digital Doctor”

Dr. Robert Wachter, author of The Digital Doctor

Mark Masselli: This is Conversations on Health C are, I’m Mark Masselli.

Margaret Flinter: And I’m Margaret Flinter.

Mark Masselli: Well Margaret , we have reached a milestone in America health care.

Margaret Flinter: Health spending has finally topped the $3 trillion a year m ark. That’s
approaching 20% of the nation’s total Gross Domestic Product just an astounding
amount of money being spent per year on health care in this country.

Mark Masselli: I t c ertainly is . And analysts estimate that w e are short about $10,000
per capita per year spent on health care delivery about twice per capita what our closest
competitor spend, the only problem is it hasn’t changed the fact that the U . S . still ranks
last among western nations in terms of health out comes.

Margaret Flinter: Prior to the passage of the Affordable Care Act annual health cost
increases were in the double digits, provisions in a law are aimed at keeping cost down
and we did see a dramatic drop in the rate of annual health spending over t he past
decade. But nevertheless, health cost still rise every year and the question, what's
driving these cost increases?

Mark Masselli: Well Margaret it turns out that prescription drug prices are major factor.
Drug prices for health consumers in Unit ed States rose more than 12% last year alone
while the overall increase in health costs were about 5%. So clearly , drug costs are
major contributor to the overall health spending in this country and it doesn’t look like
that trend shows any sign of abatin g .

Margaret Flinter: Well certainly another contributor to rise in cost in 2014 was the
increased numbers of Americans now covered by health insurance under the Affordable
Care Act. And that is intentional that took people out of the shadows of the uninsured
and into the health care system. And over time we certainly expect that access to
preventive care and screenings and better chronic illness management will have a
positive effect on overall cost trends.

Mark Masselli: No , I think it will and in creasingly the kind of health care Americans
encounter will have a technological component to it. Medicine has entered the digital
age in the 21st century something that ou r guest today finds both fraught with promise
and cause for concern.

Margaret Flint er: Dr. Robert Wachter is the founder of the Hospitalist movement. He is
a prominent medical educator from the University of California, San Francisco School of
Medicine and the author of the critically acclaimed The Digital Doctor: Hope, Hype and
Harm a t the Dawn of Medicine’s Computer Age. He will be talking about his concerns

Dr. Robert Wachter, author of The Digital Doctor

about over - reliance on technology as a panacea for America’s health industry ills and
the need to proceed with caution.

Mark Masselli: Lori Robertson stops by, the managing edit or of FactCheck.org and is
always on the hunt for misstatements spoken about health policy in the public domain
and no matter what the topic, you can hear all of our shows by going to chcradio.com.

Margaret Flinter: And as always if you have comments, ple ase email us at
[email protected] or find us on Facebook or Twitter because we love hearing from
you. Now we will get to our interview with Dr. Robert Wachter in just a moment.

Mark Masselli: But first here is our producer Marianne O'Hare with this week's headline
news.

(Music)

Marianne O'Hare: I'm Marianne O'Hare with these health care headlines. A million and
counting Open Enrollment for next year’s health coverage is marking some progress as
we approach the en d of the year. HHS Secretary Sylvia Burwell saying, a million new
customers have already signed up for coverage. The surge of interest before the end of
December guarantees those who sign up by the 15th will be covered in time for the first
of the year, and those who don’t sign up by the end of Open Enrollment and remain
uninsured face a tax penalty in the coming year.

Some end of year penalties for several hundred hospitals across the country this year
Medicare penalizing 758 hospitals for raking in high er rates of patients’ safety issues.
The fines to the hospitals total close to $400 million the most common patient harm
issues, higher rates of sepsis , hospital acquired infections and broken hips. Each year
Medicare also docks to payoff hospitals with too many patients coming back within a
month and doles out bonuses and penalties to hospital based on patient satisfaction
scores , death rates and other performance measures.

Meanwhile hospital officials are concerned these measur es are punitive and take away
funds needed to make the necessary patient safety improvements. And the
Netherlands not a country to shy away from smok e ble products but they have had time
to analyze vaping and they found a higher cancer risks from previousl y thought among
E - cigarette users the Netherlands considering a ban on anyone under 18 from being
allowed to legally smoke or vape as it's called.

A recent U . S . study showed teens and young adults who vap e are more likely to
graduate to smoking combustible cigarettes than those who do not and market for E -
cigarettes is growing fast around the world is conventional smoking to clients and

Dr. Robert Wachter, author of The Digital Doctor

response to massive public health campaigns and high syntax is imposed on smoking.
I am Marianne O'Hare with these health care headlines.

(Music)

Mark Masselli: We are speaking today with Dr. Robert Wachter , Associate Chairman of
The Department of Medicine at The University of California, San Francisco. Dr.
Wachter coined the phrase hospitalist and is considered to be an a cademic leader of
the Hospitalist movement a prolific writer on patient safety and health care quality. He
is the editor of several journals and he has written several books including the latest,
The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.
Dr. Wachter welcome to Conversations on Health C are.

Dr. Robert Wachter: Thank you so much for having me.

Mark Masselli: You said that we are at the dawn of medicine’s computer age but you
cautioned that technology is neither th e silver bullet nor the panacea that will fix what's
ailing modern health care. And you say , despite being staffed with mostly well - trained
and committed doctors and nurses, our system delivers evidence based care only about
half the time. You love medic ine and technology but you feel so strongly about the
potential harm of the emerging use of digital technology in health care and why
clinicians and patients alike should be concerned. Can you tell our listeners more about
that?

Dr. Robert Wachter: For s omeone like me who studies patients’ safety we have been
waiting computers for over a decade to come in and solve all of the problems of health
care. And then when computers finally entered our world - - and it's been remarkably
recently , I began noticing funny things and doctors and patients not looking each other
in the eye anymore. And changes in workflow that were surprising, we didn’t go down
to radiology rounds anymore because we didn’t have to. So I have been thinking kind
of a lot about what went wrong and what these changes were. And then about two
years ago at UCSF which is a fabulous place , we gave a kid a 39 - fold overdose of a
common antibiotic. And at that moment I came home and I said I need to understand
this better and then need to write about it. And the challenge of course was writing
about it in a way that doesn’t dismiss the technology but really looks at the moment that
we are at in health care and ask why is it not reaching its potential?

Margaret Flinter: Share with us how people come together after a sentinel event like
that to say, how do we make this technology work for us?

Dr. Robert Wachter: In some ways it's easy to point your finger at Epic , Cerner or
Athena whichever company buil t your technology and say they need to fix that. We
came to realize that there were a series of policies that we created when we

Dr. Robert Wachter, author of The Digital Doctor

implemented our computer system that were perfectly well meaning and worked
reasonably well most of the time but in this case it made the work more complicated
than it needed to be. We also came to realize the system of alerts, which sounds like a
great idea this is one of the great promises of technology when I am about to write for a
medicine that a patient is allergic to, the things going to pop up and show me you know
patient is allergic to this, don’t do this. But we find that we have hundreds of thousands
of alerts going off a month just within the computer order entry system adding the alerts
in the rest of the system. N o one has flipped the classroom here and looked at it from
the standpoint of what is it going to feel like to be a doctor or a nurse or a pharmacist in
an environment where you are getting alerts every two minutes. And the answer is, you
are going to igno re them.

And then there were other issues that involved culture which is a young nurse sees an
order for 39 pills when the correct dose is 1 and says to herself, this is really weird but I
know to get to me it had to go through a doctor and a nurse and – e xcuse me -- a
pharmacist then the doctor and I would check it with my technology. And so she
barcodes it and by that stage with the medication process the barcode’s job is to send
the order and the barcode confirms that that’s correct order.

So we had wor k to do on trying to convince people that when your spidey sense tells
you that something seems really kind of bizarre trust it, don’t over trust the technology
and don’t hesitate to pull the cord and say it's time to stop the assembly line let's ask a
que stion here. So these are in some ways predictable problems but I think for many of
us in health care they surprised us and we are just beginning to address them.

Mark Masselli: You ’ ve talked and written about the HITECH Act. You have some real
concerns about the HITECH Act. Was it too much money all at once? Where did we go
wrong?

Dr. Robert Wachter: The HITECH Act, was actually an amazing back story in 2004
President Bush announced in The State of Union address a federal goal of
computerizing the hea lth care system. The health care, there are differences that made
it such that health care was not going digital on its own but the initial budget to do that
was $42 million. So that’s try to transform these $3 trillion health care economy that’s
like trying to change the direction of battleship by sticking your feet in the ocean and
kicking hard. It's not possible.

And then what happened in 2008 was the economy imploded and they were coming up
with a $700 billion stimulus package to revive the economy and some smart health
policy leaders said here’s our one chance that it will last for about five minutes and then
go away forever and that was HITECH . S o that was $30 billion of federal incentives
that got us to go digital. And I am actually not critica l of those decisions nor of HITECH,

Dr. Robert Wachter, author of The Digital Doctor

I think the idea of the federal incentive program to try to push us over the line , to hit a
tipping point where doctors and hospitals would go from analog to digital I think was
smart it was happening on its own but unbe lievably slowly and I think it has worked. So
we are up to 70% EHR adoption in hospitals and doctors ’ offices we were 10% six years
ago.

Where I get critical of the government here is when HITECH was passed, they quite
sensibly said, we better have anothe r set of policies that ensure that people just don’t
accept the federal money and stick this thing on the shelf. And so we are going to
create another set of policies that’s called meaningful use. So basically if you were
going to give you federal money you need to demonstrate that you are using the
computer in a meaningful way, that’s not silly because the risk was real.

But what happened with that was the federal government got very deeply into the
weeds of essentially prescribing what your computer sys tem should and shouldn’t do.
But a lot of that is not okay and I think we are in the weeds now. There’s a model of the
feds getting this right and the model is the Internet where in the early days, the Internet
was invented by federal researchers with fe deral dollars and then they realized very
quickly that, it's time for us to pull out and it worked spectacularly well.

The market forces through the ACA and other mechanisms that are driving health care
systems to me are good enough that if you have a comp uter system you will tweak it in
the ways you need to , to meet those ultimate goals.

Margaret Flinter: It is a fascinating area and we have had the pleasure of talking over
the years with David Brailer and Dr. Blument h al, Dr. Mostashari meaningful useful as
the first phase of it, a tremendous boon to practices who were trying to shoulder the
cost of implementing electronic health records really helped to get people out of those
paper charts and enter in electronic health record , it doesn’t seem to me it's likely that
your average independent small practice can be meaningful use 2 or 3, and I wonder if
you like to comment on that and sort of the gains and the losses when we do that.

Dr. Robert Wachter: I think there is a general bias in federal policy making, the health
care should run more like a business and the set of incentives that allow the creation of
a Google or an Apple or another high functioning company tend not to be in existence in
health care and if they were in existenc e they would drive towards larger more system
kind of organizations with better use of data.

I am probably a little bit biased because I live in San Francisco and we are Kaiser
Permanente such a dominant system and I think works pretty well. I mean I thin k that
the model of a true system of the doctors and nurses and hospitals and they are all
being part of the system getting a dollar and distributing it as they see fit to deliver the
best outcomes at low cost I think that makes more sense as an organizati onal principal.

Dr. Robert Wachter, author of The Digital Doctor

I guess my hope is that with new IT tools and with an increasing focus on the metrics
that we care about that there will be a way to create sort of the best experience for
patients in the context of the benefits that a larger system can bri ng. Increasingly
people will get some of their health care or maybe a lot of their health care from their
home or their workplace enabled by new technology tools or telemedicine. But it all has
to sit together in this pretty complicated jigsaw puzzle and I think it's more likely that we
will succeed in achieving the goals that people are glue d together in larger system.

Mark Masselli: We are speaking today with Dr. Robert Wachter , Associate Chairman of
The Department of Medicine at The University of Cali fornia, San Francisco. Dr.
Wachter coined the phrase hospitalist , he is author of The Digital Doctor: Hope, Hype
and Harm at the Dawn of Medicine’s Computer Age. You make an elegant case for the
emerging health care system that’s not only based on man ve rsus machine but rather
on two elements working together in tandem . Tell our listeners more about where the
medical profession might be heading in our newly wired world.

Dr. Robert Wachter: I had this epiphany a year and a half ago that I needed to write
about this but I am not a techie person at heart and so my wife is a journalist who writes
for The New York Times and she suggested to me that the only way I was going to get
this write was to do a journalistically . A nd that meant I interview about 90 pe ople
including all The Office o f National Coordinator director so you decided and went to see
primary care docs during their work [inaudible 00:14:31 ] but when I asked them, where
does this all end up if we get it right ? The vision that almost everybody had was about
the same and it was actually quite nice and you know patients are getting digitally
enabled care in their homes and their workplaces. We are using big data technology
brings us closer to patient s and brings patients close r to each other . S o I profiled one of
these peer to peer sites called Smart Patients where patient s get diagnosed with cancer
and they go on the web and they talk to other patients with the same cancer and they
learn a tremendous amount fro m that.

This sort of man versus machine I think is in some ways an artificial argument that when
you get it right it's not, these two are not in competition, these two weave together in
new and wonderful ways. And I think it takes 10 or 15 years for the t echnology to settle
into a new industry and make things really measurably better where at the stage in
health care where I think we broaden the technology and we didn’t re - imagine the work
or why shouldn’t it look like Facebook or Twitter where there is so rt of a stream of
information that everybody contributes to including the patient. I don’t think we have
thought deeply enough about what are our goals and how do this technology help us
reach those goals.

Margaret Flinter: I think we would be remiss giv en your leadership in the area of
developing the role of the hospitalist in that giving an opportunity to comment on that as

Dr. Robert Wachter, author of The Digital Doctor

well because certainly for a generation it was physicians who were disrupted by this in
primary care and community medicine spent y ears and decades in many cases with the
hospital ist s it's kind of their daily social [inaudible 00:16:03 ] before they went back to the
relative isolation of their practices and the hospitalist movement as it developed for all
the very good reasons develope d really was a big dislocation. What's the jury verdict on
the gain and the loss around the almost complete transition now to the hospitalist
movement around the country?

Dr. Robert Wachter: I have a strong belief that the organization of care with a sep arate
hospital doctor achieves more gains than losses. The old notion of your doctor, your
regular doctor taking care of you in the hospital is attractive in all sorts of ways but in the
era of patients who are in the hospital being really sick, the pace being incredibly fast , I
think you need a doctor there all day long. And my model for this when I coin the term
and kind of begin to thinking about this, in the old days there were no critical care
doctors and then people realized that you need a physicia n, a generalist physician who
is essentially a specialist in the place. And ultimately now the hospital has become as
complicated a place you can't have a patient being managed by someone who has a
different job 10 hours of the day.

I think the data say t hat on average quality and safety are at least neutral if not better
where I think things really get exciting is the maturation of the hospitals field because
what we did was position the field as being a new kind of a doctor, a doctor who would
not only t ake care of the individual patient but also be a steward of the system and pay
a lot of attention to this other sick patient meaning the health care system.

As I look at my group at UCSF we are the unquestioned leaders in the organization in
improving the system. It's not a coincident I believe that the Surgeon General is now a
hospitalist and the top physician at Medicare is now a hospitalist. It's a young field but I
think we have bred a disproportionate number of leaders in these areas because we
have a deep belief that we did need a different kind of physician who paid attention to
improving the system as well as individual patient care. But it means we have to pay a
lot of attention to how do we move information back and forth but in a good system
people actually speak to or email each other to make sure there is a personal
connection.

When I look at a high functioning multispecialty group, when I look a t Kaiser
Permanente or Geisinger or Palo Alto Medical Clinic I think what they have done is they
have created environment in the ambulatory setting where physicians get much of that
joy and benefits and collegiality. So I think it's in some ways another a rgument against
the one or two person practice. I thi nk we need larger organization or units to kind of re -
imagine the environment in which physicians will get that kind of professional benefit.

Dr. Robert Wachter, author of The Digital Doctor

Mark Masselli: We have been speaking today with Dr. Robert Wachter , Associate
Chairman of The Department of Medicine at The University of California, San Francisco,
chief of Hospital Medicine and Medical Services at UCSF Medical Center and author of
The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.
You can learn more about his work by going to the - hospitalist.org. Dr. Wachter thank
you so much for joining us on Conversations on Health C are.

Dr. Robert Wachter: It's been a great pleasure.

(Music)

Mark Masselli: At Conversations on H ealth C are, we want our audience to be truly in
the know when it comes to the facts about health care reform and policy. Lori
Robertson is an award - winning journalist and managing editor of FactCheck.org, a
nonpartisan, nonprofit consumer advocate for vot ers that aim to reduce the level of
deception in U . S . politics. Lori what have you got for us this week?

Lori Robertson: Due to vast majority of American support def unding Planned
Parenthood that’s what republican presidential candidate Carly Fiorina cla imed. But
national surveys actually show the opposite. Most Americans support continued federal
funding for the Groups Health Services. The controversy over federal funding a
Planned Parenthood has come in response to undercover videos taken by an anti -
abortion group that show Planned Parenthood officials discussing compensation for
fetal tissue with people posing as employees of a company looking to procure tissue for
research purposes.

Federal funding for abortion is restricted by the Hyde Amendment to only abortion cases
involving rape, incest or endangerment to the life of the mother. At Planned Parenthood
clinics in 2013 abortions accounted for 3% of the nearly 10.6 million total services
provided by the group according to its annual report. We fou nd several public opinion
polls that found most American survey to support continued funding for Planned
Parenthood.

For example, a Pew Research Center poll conducted in late September found that 60%
said any congressional budget deal must maintain funding for Planned Parenthood,
32% says that any agreement must eliminate such funding. A Reuters/Ipsos poll
released in A ugust found that 54% supported federal funding of Planned Parenthood
with 26% opposing it. A USA Today S uffolk University Poll from late September found
that 65% of those surveys said, federal funding of Planned Parenthood should continue
while 29% said it should be eliminated. And there are other polls with similar findings.

We also consulted Marquette Uni versity ’s Charles Franklin , a polling expert who runs
pollsandvotes.com to ask if he knew of any national polls that supported Fiorina’s claim.

Dr. Robert Wachter, author of The Digital Doctor

He did not. And that’s my fact check for this week, I am Lori Robertson Managing
Editor of FactCheck.org.

Marg aret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact, that you would like checked, email us at
www.chcradio.com . We will have FactCheck.org's Lori Robertson check it out for you
here on Conversations on Health C are.

(Music)

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Pregnancy is normally an
exciting time for most women but according to the research an estimated 10% of
prenatal women experience some kind of depression during their pregnancy and many
are reluctant to treat their depression with medication for fear of harming the fetus.

Dr. Cynthia Battle : In fact a higher percentages are experiencing lower grade
depressive symptoms. So they might not meet full criteria for major depressive episode
but they are hav ing significant symptoms that are getting in the way of feeling good
perhaps even getting in the way of engaging in the kind of healthy behaviors that are
going to support a healthy pregnancy and left untreated those mild to moderate
symptoms can progress and can lead to a more serious postpartum depressions.

Mark Masselli: Dr. Cynthia Battle is a psychologist at Brown University with a practice
at Women's a nd Infants Hospital a t Providence . She and her colleagues decided to test
a cohort of pregnant women to see if a targeted pre - natal yoga class which combines
exercise with mindfulness techniques might have a positive impact on women dealing
with prenatal depression.

Dr. Cynthia Battle : We worked with these experts to really come up wit h a program that
was similar to what you might find in the community of prenatal yoga that would include
physical postures, meditation, exercises. And we enrolled 34 women who are pregnant
who had clinical levels of depressions and we measured their chang e in depressive
symptoms over about a period of time.

Mark Masselli: Not only were women able to manage their depressive incidents they
also bonded with other pregnant women during the program and found additional
support from their group.

Dr. Cynthia Bat tle : We found that women on average were reporting that they were
reporting much less. Women who are depressed during pregnancy unfortunately do
often have some less ideal birth outcomes. So one thing we are interested in seeing is

Dr. Robert Wachter, author of The Digital Doctor
when we provide prena tal yoga program can it improve mood and then can we even
see some positive effects in terms of the birth outcomes.
Mark Masselli: A guided non - medical yoga exercise program designed to assist
pregnant women through depression symptoms, helping them succe ssfully navigate
those symptoms without medication ensuring a safer pregnancy and a healthier
outcome for mother and baby now that’s a bright idea.
(Music)
Margaret Flinter: This is Conversations on Health C are, I am Margaret Flinter.
Mark Masselli: And I am Mark Masselli, peace and health.
Conversations on Health C are, broadcast from the campus of WESU at Wesleyan
University, streaming live at www.wesufm.org and brought to you by the Community
Health Center.